“Ok, I want you to inhale and brace like you’re going to lift. Ready?”
 
I inhaled and braced as well as I could, considering that instead of getting ready to lift a barbell, I was naked from the waist down and lying flat on my back on the physiotherapist’s treatment table, and she had a couple of fingers inside me, checking for signs of muscle dysfunction and pelvic organ prolapse.
 
I had gone to see her for an assessment, mostly for education’s sake—I’m a personal trainer and a competitive strength athlete, and I’ve been working with female athletes at all levels for many years, so I figured I had a pretty good handle on pelvic floor care —but if I’m honest I knew in the back of my mind that something wasn’t quite right down there. Sure enough, in the initial stages of the assessment she had identified a stage two pelvic organ prolapse (POP). I had some work to do; years of heavy lifting without paying proper attention, a couple of rounds of pregnancy and childbirth, and some age-related estrogen decline had taken their toll on my pelvic floor and I had to re-learn how to use those muscles.
 
“Nope,” she said. “Do it again, but don’t push down - lift UP.” I tried again, this time being careful not to push out or down. “That’s it,” she said. “Nice work. Do it again.”
 
What is the pelvic floor? We’ve all heard of it, but we don’t really talk about it except when we’re whispering to our female gym buddies about peeing during max effort lifting, jumping, or running. Simply put, the pelvic floor is a muscle group, same as the quadriceps, glutes, or rotator cuff. Its main job is to stabilize the pelvis and spine, but it is also the sling that provides support for all the pelvic organs, and the bottom floor of the abdominal capsule or canister whose integrity we rely on when we lift weights.
 
If we are going to be strong athletes, we need all of our muscles to be strong together. If something goes wrong in our rotator cuff, we go get it checked out, and then we do some rehab work to get it strong again. If we start getting impingement in our hips, we get it checked out and then we do some rehab work to get it strong again. But if we start peeing on the platform during heavy lifts or with impact, or if we develop strange feelings of heaviness down there, we have developed an unhealthy tendency to roll our eyes and say, “Oh well, that happens to everybody; nothing to worry about.”
 
While it’s good that we’re talking about it—pelvic floor dysfunction (PFD) is nothing to be ashamed of—it’s important to note that PFD is common, but it is not normal. It means that when things aren’t working right, we need to (you guessed it) get it checked out, and then do some rehab work to get it strong again. That goes double for female athletes, because our sports put a higher demand on our bodies than most activities of daily living (except for maybe shopping at Costco). We need to pay some extra attention to keeping all of our muscles healthy and strong and happy—even the ones in our basements that no one wants to talk about.
The problem with being a female strength athlete is that most of the research on strength and athletic performance has been done on male subjects. Women have only had the opportunity to compete in strength sports for 40 or so years, first in bodybuilding in 1977 and powerlifting in 1978, but women’s events didn’t really become popular until the 2000s. Women didn’t compete in weightlifting at the Olympics until 2000, and the CrossFit Games made history in 2007 by introducing the male and female weightlifting categories at the same time.
 
Since then, there has been a virtual explosion of women competing in strength sports. The vast majority of the strength coaches out there are men, though, and they teach what works for them. Most of the time, this makes perfect sense. Men and women have the same muscles in the same places...with one notable exception: our pelvic anatomy is vastly different in form and function. Women have an extra opening in our pelvic floor musculature, and we need our abdomens and pelvises to be able to expand, stretch, and spread to allow for pregnancy and childbirth. As such, we have less structural integrity in our pelvic floors, which leaves us vulnerable whether or not we’ve had babies. So, we have a few extra things to consider when it comes to bracing under a heavy load: the traditional method of bracing by taking a big breath and pushing the air down and out into the belly/weightlifting belt can be hazardous to our health and detrimental to longevity in our sports. Female athletes need a different strategy.
 
Integration vs. Isolation
 
HOW do we go about caring for this temperamental yet important little muscle group? The muscles in the pelvic floor are made up of about half voluntary and half involuntary muscle tissue, which makes for an interesting challenge as far as training them is concerned. The involuntary movement of the pelvic floor works in tandem with the diaphragm to create and manage intra-abdominal pressure (IAP); when we inhale both the diaphragm and the pelvic floor descend, and when we exhale, they both ascend.
 
The first step is to learn to manage intra-abdominal pressure (IAP) so as to avoid PFD altogether. In weightlifting we need to create IAP in order to protect our spine from injury, and traditionally we are taught to do that by taking the deepest breath possible and pushing our abdominals down and out. If we’re wearing a belt, we push into the belt as hard as we can—the more pressure we can create, the more weight we can lift. In order to create a good hard brace without pushing down into the pelvic floor, we need to release a little bit of that maximal inhale; allowing the diaphragm and the pelvic floor to rise a little bit giving it some room to contract and do its job of holding in and supporting the contents of our abdomen. What we do with that last breath before we pull the bar off the floor will either make or break the lift, so this is worth practicing! (See PDF version for article images)
 
All full-body lifts (think Oly lifts, squats, and deadlifts) will have an integrated training effect, making the pelvic floor stronger automatically along with the rest of the abdominal capsule.
 
Outside of nailing in good breathing and bracing habits, the next thing to take care of is... (drumroll please) accessory work! Because we all love to neglect focus on that part of our programming. I know what you’re thinking. But it’s important, especially for lifters who spend most of their workouts moving in the sagittal plane, to keep moving our joints through full ranges of motion. Hip internal and external rotation, moving in the frontal plane, and keeping the spine and pelvis stable need to be priorities.
 
Here’s a quick little accessory circuit to keep your pelvic floor happy:

1. Bird Dogs 10/each side
2. 90/90 Press Ups 8/each side
3. Cossack Squats 6/each side

 
Hands up, who here has heard of Kegels? Kegels are an isolated pelvic floor exercise named for Dr. Arnold Kegel, a gynecologist who developed the intentional pelvic floor squeeze (as though stopping the flow mid-pee) as a treatment for urinary incontinence. Since then, Kegels have been touted as a method for reducing leakage, recovery from pregnancy and childbirth, and intensifying orgasms. Where do we sign, right? But Kegels have their drawbacks. They are not the be-all and end-all that people tend to think they are.
 
When PFD does rear its ugly head, it’s for one of two reasons:
 

1. Hypotonic Pelvic Floor: those muscles are underactive; think sleepy or stretched out or slack, possibly due to pregnancy/childbirth, OR from the drop in estrogen levels that comes with the onset of perimenopause. This doesn’t mean these muscles are weak, but it does mean that they aren’t doing their job as effectively as they should. In this case, some focused isolation exercise is a great idea and can help get those muscles fired up again.
2. Hypertonic Pelvic Floor: muscles are overactive, shortened and tight. This can be caused by chronic stress, postural problems, or from overdoing Kegels incorrectly—which is more common than you might think! If you are suffering from tightness in the pelvic floor muscles, Kegels are only going to make the problem worse. You don’t want to take an overworked, tight muscle and work it harder! Instead, we want to get those muscles re-connected with targeted stretching and breathing drills.

 
Either way, if there are problems going on with your pelvic floor, PLEASE go and see a pelvic floor PT to identify the problem and to make a plan for recovery. The good news is that with some awareness and some extra attention, it usually doesn’t take that long to get things connected and working again.